Moral/ethical dilemma concerning a pt's right to refuse.

[tniuqs]

'Lone Star' date='21 September 2009 - 06:55 AM' timestamp='1253541342' post='223874']

Whoa, Nellie!

WOW harsh words there LS ...

Dwayne,

I commend you on stepping up as a patient advocate!

Agreed.

My opinion for what it matters is that Dwayne can walk away with his head held high for doing the morally correct thing, anything else is a cop out no matter how wants to spin it.

Dwayne is the type of Paramedic that I would want to treat me or my family, a rational caring individual that is sensitive to the patients needs. The laws of the land ARE subject to interpretation their not all black and white,one must look to the intent of the law I just cant see a court case stemming from his actions in the slightest, we often confuse the "patients rights" with what is the "right thing to do" and if living in fear of the law and negative repercussions then one should reevaluate what we actually stand for.

Did the Good Samaritan have a refusal form ? just saying ........

cheers

Edited September 21, 2009 by tniuqs

[DwayneEMTP]

Because that is the framework in which we are arguing. Again, the conditions Dwayne has stipulated are:

1. This was a hypoglycemic episode.

2. Treatment was available inside the home.

3. After treatment was administered, the patient would refuse.

4. Treatment was delayed for the specific intention of avoiding a refusal.

Unless I'm missing something here, I thought we were discussing this isolated moral/philosophical point.

You are absolutely right on all points.

There was no disagreement that practically what Dwayne did could likely be justified. If you isolate the moral issue though, using the stipulations above, the argument may be different. I think if Dwayne got stood up in a court of law and said that he delayed treatment SPECIFICALLY to take away this patient's ability to choose, I think he would be in some trouble. That is what I thought we were discussing.

Devil's advocate....

Though I've run on attempted/threats of suicide that I would be unable to prove were in any way altered, (calm, lucid, drug/alcohol free)we still manage these patients with transport, right? Even against their will if necessary as we've found that though they are mentating in every way 'normally' these types of thoughts are considered 'altered.' (in an effort to keep the thought in context.)

So could it be extrapolated that if purposely planning to take your life via mechanical means is 'disallowed' as damaged thinking that then choosing to risk your life via non management of an relatively easily managed disease might be so as well? Is evidence that you're willing to willing to cause/allow/or in some way bring about your own demise defined by semantics, or intent? (Of course, should this pt have a DNR for this, or some other reason, I would consider this argument moot.)

If the argument isn't what I think it is, I still say that I would not delay treatment. As I mentioned earlier, Dwayne could have caused his patient harm by delaying treatment, and in my opinion put the patient at an unnecessary risk by doing so. Unless there is a MEDICAL (or safety) reason not to, I treat all of these patients where I find them.

Can the argument be made that by treating this patient in place, with the belief that he would refuse, actually be the choice that will put the patient at more substantial risk? Is he better served to be awakened and then left to suffer his next crisis alone, which is nearly assured, than to have his treatment monitored even by a half assed paramedic for the few moment trip to the ambulance?

Thanks all for your responses! This is an awesome exercise! Though perhaps more easily than before, with the last several posts it's easy to argue that what was done was right because it feels right.

I'd ask as a favor that we continue to follow Fiz's example of staying focused and within the parameters of the argument. Not because the other points of view are unimportant, or uninteresting, as I find them just the opposite, but simply because we're gifted with having many of our most valuable posters in this thread and it will help us all stay on track.

Thank you all for participating in the very best spirit of EMTCity...that's cool as hell.

Dwayne

[Lone Star]

WOW harsh words there LS ...

Easy there tniuqs! I didn't realize that 'cowboy talk' would frighten you like that!

I'll try to 'tone it down' in the future, so you're not having to hide under your desk!

Edited September 21, 2009 by Lone Star

[cosgrojo]

So for the purpose of argument, we may stipulate:

1. You thought that the patient was suffering from a hypoglycemic episode.

2. You knew this condition was treatable by you "inside the home" (as rapidly as possible).

3. You thought that if treated, the patient would return to his baseline mental status and refuse further care.

4. You chose to delay treatment for the express purpose of avoiding a refusal (not for any other medical reason).

OK, I'll play along... but I do not believe that these were the parameters of the actual call Dwayne was on... the scenario was neither as simplistic, nor as rigid as these rules.

Fiz- my only problem with your opinion is that regardless of what the provider "thought," we do not have enough information about the patient to come to any definitive diagnosis. While your first thought (#1 stipulation) is logical, and we have enough differential information to deduce the issue with a fair level of certainty; the second thought (#3 stipulation) is grossly assumptive, and shouldn't enter your mind as a provider who is always on the lookout to treat the worst case scenario. If the provider could guarantee that #3 is the case, then that person missed their calling as a professional prognosticator. While there is nothing wrong with understanding the normal process of the hypoglycemic emergency, there is something wrong with assuming that it will always be that way.

As far as stipulation #4 goes... I don't know anyone that would turn down the opportunity to get a refusal if you didn't think that there was any medical reason to transport the patient (barring obvious reportable environmental factors). If for some reason the provider just hates doing refusals, and would rather just transport a person who does not require, or want our services... then we have a clear ethical compromise, and delaying the treatment would only be the tip of that ethical ice-burg.

It is our duty to think not only what we think is going on, but also what else might be going on. We are not supposed to put ourselves in positions where tunnel vision dictates our treatment... so why let it dictate our ethics?

*edited for innapropriate use of a form of "There & Their"*

Edited September 22, 2009 by cosgrojo